0001-160 (RR)LICENSED CONTRACTOR DECLARATION
•1 hereby affirm under penalty of perjury. that I 'am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # :' Lic. Class - Exp. Date
j r ,1
ate `� ` f; Si nature, of Contractor
,OWNER -BUILDER DECLARATION', i
i.
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner'of the property, or my employees with wages'as their sole
compensation, will do the work,'and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively 'contracting,.with licensed
contractors -to -construct'the -project.(Sec.=7044,'Business & Professionals
Code). '
O I am exempt. under Section B&P.C: for this reason
Date..Signature of Owner
WORKER'S COMPENSATION DECLARATION'
• I hereby -affirm under penalty of perjury one of the-'following'declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor. Code, for the
performance of the work for which this permit is issued'.
'(Y) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.: My workers' compensation insurance carrier & policy no. are:
Carrier�♦,t� Policy No.. . y
Y,LL.7t+INi�i r� ��. Ll�w4...i.r� � .. �k�.e.^4V €; 5.•
(This section need not be.completed if the permit valuation is for $100.00 or less).
( ) ' I certify that in the performance of'the work for which this permit is issued,
I shall not,employ. any. person in any° manner so as to become subject to the
workers' compensation laws of California, and agree that if -I should become.,
subject to the�workers' :compensation provisions of Section 3700 of the Labor
Code, I shall,forthw1,th comply with those provisions.
Date: '%pplicant/�
9
Warni g Fail to secure C/ 6"
coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up'to $100,000, in . .
addition to the cost of compensation, damages as provided for. in Section 3706
of the Labor Code', interest and attorney's fees. ,
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit' subject to ,the conditions and restrictions set, forth on his,
application.
1. Each person upon whose behalf this application is made & each person at
whose request and.for whose benefit work is performed under or. pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not, commenced within 180 days, from, date of issuance of such
permit, or cessation of work for 180 days will subject permit`to:cancellation.
.r
I certify that I have read this application and state that the above information is
correct. I agree to, comply with all City, and State laws relating to the building
construetion, and hereby authorize representatives of this City,to enter upon
the above-mentioned property for inspection purposes:'
Signature (Owner/Agent)" `� `����/ Date f✓
BUILDING PERMIT PERMIT#
DATE 0,1JJ.)!'ZJD0VALUATION✓ _ . 3p�� Q�,� LOT �+--TRACT
n
JOB SITE. e
ADDRESS nr i t 'a. a. cx -
API
773•.+d-:l1i .
OWNER
CONTRACTOR / DESIGNER / ENGINEER
i.rtiA
�,�""",�l��i.iiW iidc�•.•,�� �.'.ei. •
5267 0 A VRii<'i. A VfLL
.AC
38,0801U011C:HO 1.,05 COME
LA C7WNTA CA 9223 �
;LRD10
CA
9229-1 '
(760)1453751.
r-JIU ' !2
USE OF PERMIT
71
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7.,r
v:f2GCai" 3,1:50.00 LS
.7V.S :IVNI V11 1. D i_VSh OF
77,, •��,`+, ee.g'j" y '�'� •• � 77 ¢¢�Tyy aa
iv
t Et2t ►V ' t E 101-0(10.418-000
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ST t . it„Tl /tr crs at.� art �Jc:':�'�E?t N PLAN C1+ a
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Rrc•o r•�*� 'n i'iT,
a s.
'S DUE
S30.00
'
RECEIPT
DATE
BY
DAJE I AL DQ�
INSPECTOR
+.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Roof Deck , 12-z- —'
Combustion Air
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Insulation
_
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWALL APPROVALS
Final
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
'